Chronic kidney disease (CKD) is a worldwide public
health problem. Nepal is one of the poorest countries in the world and has grossly
limited treatment options for CKD and ESRD. For a population of 27 million,
there are 16 renal physicians, most of the dialysis centers are located in the
major cities, and there is very limited public money expended on health care. Indeed,
only two nephrologists serve outside the capital city Kathmandu.
In Nepal the cost per month treatment per patient
for hemodialysis is more than the per capita gross national product (GNP) of
the country, making renal replacement therapy (RRT) a rare choice for the
majority of individuals who develop ESRD. Twice-a-week hemodialysis is the
usual practice with re-processing and re-use of the dialyzer being common. The
cost of hemodialysis is approximately US $250 to 300/month at government
centers, and US $300 to 500/month at private centers, and this excludes the
cost of erythropoietin and other medications. The cost for CAPD is even higher.
Although kidney transplant was initiated in 2008 in Nepal, it remains out of
reach for most of the ESRD population due to cost and the unavailability of
either living or deceased donors.
Another major issue is the
limitation of available dialysis facilities. Dialysis is available in only the
5 major cities of Nepal. Therefore, because of the cost and complexity of RRT,
less than 5% of the population who develop ESRD receives any form of renal
replacement therapy.
The very limited resources
for nephrology care underscore the urgent need for establishing preventive
programs for renal disease. Before advocating for action on prevention,
however, it would be useful to understand the prevalence of CKD and its risk
factors, but so far even this information is unavailable in Nepal.
Screening for CKD in Nepal
In the international
nephrology community there is a broad consensus that screening programs should
be targeted towards individuals at “high risk” of kidney disease. It is argued
that this is cost-effective. These “high-risk” individuals include those with
diabetes, hypertension and proteinuria.
In Nepal and I would guess
in other low income countries, screening targeted at people aware they have
risk factors for kidney disease would mean that large chunks of the population
with kidney disease risk factors would go remain unscreened.
In Nepal, people do not
seek medical advice regularly. Foremost among the reasons for this is a lack of
awareness of disease. However, there is also this belief that the absence of
symptoms must mean good health even though there might be a family history or
risk factors for kidney disease. There is also the problem of losing a day of wages
from missing work to go the doctor.
In Nepal our studies show
that is a very low awareness for diabetes, hypertension and proteinuria (1).
Individuals are referred to nephrologists very late, frequently at the point
that they need imminent dialysis. Because of the limited resources, nothing
much can be done for these patients and physicians are left with the unenviable
task of pronouncing a “death sentence verdict”.
I recognize that there is
no easy solution to the problem. Chronic diseases are on the rise and
nephrology is not the only health issue that the government has to address. Infection,
gastrointestinal, maternal and child health issues continue to strain both
medical and financial resources. Furthermore, Nepal’s public health infrastructure
remains dilapidated.
Our own experience in a community-based screening and intervention program is based on the ISN's model - "Program for Detection and Management of Chronic Kidney Disease, Hypertension, Diabetes and Cardiovascular Disease in Developing Countries" (KHDC). We observed that impaired kidney function, proteinuria, hypertension, diabetes, smoking,
sedentary life style and obesity are common even in younger participants.
Consequently, incident cases of CKD, proteinuria and cardiovascular disease
will likely increase substantially over the coming decades.
Community-based Screening: KHDC-Nepal
 |
| Fig.1: Screening for CKD |
(1) Epidemiological surveillance
(2) Primary prevention (preventing disease in
healthy populations); (3) Secondary prevention (preventing complications and
improving quality of life in affected communities).
Our goal has been to
develop interventions within a 'multifaceted and multi-institutional' framework
that makes efficient use of existing economic and human resources even though
both are currently inadequate.
 |
| Fig. 2: Awareness Bike Ride |
We have collaborated with members of the local
community and their leaders. We
have sought to develop large and sustained educational programs for people and
healthcare workers while in parallel developed an organizational network of
doctors, medical students, nurses and volunteers under an academic coordinating
center. This collaborative model has been necessary to assure smooth and
reliable screenings and, far more important, to efficiently use the limited
resources and interventions.
We believe that our
collaborative approach is essential to help reverse the negative trend in the
incidence of kidney disease in an emerging country like Nepal and overcome the
cost and complexity of RRT which is currently beyond the reach of most citizens
living in our country.
References
1. Sharma SK, Zou H, Togtokh A, Ene-Iordache
B, et al. Burden of CKD, proteinuria, and cardiovascular risk
among Chinese, Mongolian, and Nepalese participants in the International
Society of Nephrology screening programs. Am J Kidney Dis 2010; 56(5): 915-27.
2. Li PK, Chow MK,, Matsuo
S et al Asian chronic kidney disease best practice recommendations: Positional
statements for early detection of chronic kidney disease from Asian Forum for
Chronic Kidney Disease Initiatives (AFCKDI). Nephrology 16 (2011) 633–641
3. Mani MK. Experience
with a program for prevention of chronic renal failure in India. Kidney Int
Suppl 2005; S75–S78.
